HEALTH ASSESSMENT.

HEALTH ASSESSMENT

HOUSE RULES Come to class on time, in the right uniform, and well-groomed. Extend courtesy not only to the Professor but to everyone as well. Act like future Professional Nurses. Gadgets ARE NOT ALLOWED AT ALL TIMES inside the classroom. Listen attentively, take down notes, and PARTICIPATE ACTIVELY. Present Admission Slip if absent. Three tardiness is equivalent to one day absence from class.

HEALTH ASSESSMENT The course deals with concepts, principles & techniques of history taking using various tools, physical examination (head to toe), psychosocial assessment and interpretation of laboratory findings to arrive at a nursing diagnosis on the client across the lifespan in community and hospital settings.

TERMINAL COMPETENCIES
At the end of the course (36 hours) and given simulated and actual conditions/ situations, the student will be able to: Differentiate normal from abnormal assessment findings; Utilize concepts, principles, techniques and appropriate assessment tools in the assessment of individual client with varying age group and development; Observe bioethical concepts/ principles and core values and nursing standards in the care of clients.

NURSING PROCESS Sets of actions used to determine, plan, implement and evaluate nursing care. Systematic, rational method of planning and providing individualized care.

PURPOSE To help the nurse manage each patient’s nursing care, intelligently, scientifically and judiciously.

CHARACTERISTICS It is problem-oriented It is goal-oriented It is orderly and planned, step-by-step It is universally applicable to all patients, families, and communities that nursing serves

FIVE COMPONENTS OF THE NURSING PROCESS
Assessment Nursing Diagnosis Planning Implementation Evaluation

Overview of the Nursing Process
Assessing- collecting, organizing, validating, and documenting client data. Diagnosing- analyzing and synthesizing data Planning- determining how to prevent, reduce, or resolve the identified priority client problems. Implementing- carrying out (or delegating) and documenting the planned nursing interventions. Evaluating- measuring the degree to which goals/ outcomes have been achieved.

Nursing Process in Action
Assessing - collect data, organize data, validate data, document data Diagnosing - analyze data, identify health problems, risks and strengths, formulate diagnostic statements Planning Prioritize problems/diagnoses, formulate goals/desired outcomes, select nursing interventions, write nursing interventions

Implementing Reassess the client, determine the nurse’s need for assistance, implement the nursing interventions, supervise delegated care, document nursing activities Evaluating Collect data related to outcomes, compare data with outcomes, relate nursing actions to client goals/outcomes, draw conclusions about problem status, continue, modify, or terminate the client’s care plan.

Assessment: The First Phase of the Nursing Process
the most critical phase of the nursing process deliberate and systematic collection of data to determine client’s current and past health and functional status. determines client’s current and past coping patterns

Assessment: The First Phase of the Nursing Process
is ongoing and continuous throughout all the phases of the nursing process.

A Critical Thinking Approach to Assessment
Analysis Client’s Record Client Client’s Significant others Health Team Members

Subjective & Objective Data
Subjective Data Objective Data data are elicited and verified by the client data are directly or indirectly observed or measured method used to obtain data: Interview method used to obtain data: observation & physical exam skills needed to obtain data: interview and therapeutic communication skills, caring ability, empathy, listening skills skills needed to obtain data: inspection, palpation, percussion, auscultation examples: “I can’t see clearly”, “My backache is worsening each day”, “I give up”, “I know God is with me in all of these” examples: reddened patches all over posterior chest, bipedal edema, BP: 90/60 mmHg, weight: 55kg, height: 185cms

HEALTH HISTORY GUIDELINES
INTERVIEW A planned communication or a conversation with a purpose

PURPOSES OF INTERVIEW Get or give information Identify problems of mutual concern Evaluate change Teach Provide counseling or therapy

Approaches to Interviewing
DIRECTIVE INTERVIEW Highly structured, elicits specific information Nurse establishes purpose of and controls the interview Used to gather and get information when time is limited

Approaches to Interviewing
2. NON-DIRECTIVE INTERVIEW Rapport building Nurse allows client to control the purpose, subject matter, and pacing. NOTE: A combination of Directive and Non-directive interview approaches is usually appropriate during information-gathering interview.

TYPES OF COMMUNICATION
VERBAL NON-VERBAL

Types of Interview Questions
1. CLOSED-ENDED QUESTIONS Used in directive interview Restrictive, generally requires a “yes” or “no” or short factual answers giving specific information Often begin with “when”, “where”, “who”, “what”, “do (did,does)”, “is (are, was)”

2. OPEN-ENDED QUESTIONS Used in non-directive interview Invite clients to discover and explore, elaborate, clarify, illustrate their thoughts or feelings Answers are longer than two words Gives clients freedom to divulge information that they are ready to disclose Useful in the beginning of an interview or to change topics and to elicit attitudes May begin with “what” or “how”

3. NEUTRAL QUESTIONS Client can answer without direction or pressure from the nurse Is open-ended, used in non- directive interviews

4. LEADING QUESTIONS Is closed, used in directive interview Directs client’s answer Gives clients less opportunity to decide whether the answer is true or not

NON VERBAL COMMUNICATION
FACIAL EXPRESSION ATTITUDE SILENCE LISTENING

STRUCTURE/PHASES OF AN INTERVIEW
OPENING (or Introductory) Most important part of the interview, sets tone for the remainder of the interview Purpose is to establish rapport and orient the interviewee The nurse must be careful not to overdo this stage In this stage, the Nurse explains the purpose & nature of the interview, like what information is needed, how long will it take, & what is expected of the client, how the information will be used, & that the client has the right not to provide data.

STRUCTURE OF AN INTERVIEW
2. BODY (Working) Client communicates what he or she thinks, feels, knows, perceives in response to questions from the nurse. Effective development of the interview demands that the nurse use communication techniques that make both parties feel comfortable & serve the purpose of the interview

3. CLOSING (Summary and Closing) The nurse terminates the interview when the needed information has been obtained. In some cases, the client may terminates the interview Closing is important for maintaining the rapport and trust and for facilitating future interactions.

The following techniques are commonly used to close an interview: Offer to answer questions. Conclude by saying “Well, that’s all I need to know for now.” Preceding a remark with the word ‘well’ generally signals that the end of the interaction ids near. Thank the client. You may also shake the client’s hand. Express concern for the person’s welfare and future. Plan for the next meeting, if there is to be one, or state when it will happen next.. Include the day, time, place, topic, and purpose. Provide summary to verify accuracy & agreement. Summarizing not only terminates the interview but also reassures the client that the nurse has listened.

PLANNING THE INTERVIEW AND SETTING
Nurse should review available information. Nurse reviews the institution’s data collection form if there’s any, otherwise, the nurse may prepare an interview guide.

CONSIDERATIONS DURING AN INTERVIEW
Time Place Seating Arrangement Distance Language

GUIDELINES DURING AN INTERVIEW
Listen attentively, using all your senses, and speak slowly and clearly. Clarify points that are not understood. Plan questions to follow a logical sequence. Ask only one question at a time. Multiple questions limit the client to one choice and may confuse the client.

Acknowledge the client’s right to look at things the way they appear to him and not the way they appear to the nurse or someone else. Do not impose your own values on the client. Avoid using personal examples, such as saying, “if I were you,…” Nonverbally convey respect, concern, interest, and acceptance.

Be aware of the client’s and your own body language. Be conscious of the client’s and your own voice inflection, tone, and affect. Sit down to talk with the client (be at an even level). Use & accept silence to help the client search for more thoughts or to organize them. Use eye contact to be calm, unhurried, and sympathetic.

Interview Guidelines gerontologic variations in communication
cultural variations emotional variations

Gordon's Functional Health Patterns

Marjorie Gordon (1987) proposed functional health patterns as a guide for establishing a comprehensive nursing data base. These 11 categories make possible a systematic and standardized approach to data collection, and enable the nurse to determine the following aspects of health and human function:

Gordon's 11 Functional Health Patterns
Health Perception and Health Management. Nutrition and Metabolism Elimination Activity and Exercise. Cognition and Perception. Sleep and Rest. Self-Perception and Self-Concept. Roles and Relationships. Sexuality and Reproduction. Coping and Stress Tolerance. Values and Belief.

HEALTH PERCEPTION & MANAGEMENT
Describes the client’s perceived health & well being and how health is managed. HEALTH PERCEPTION & MANAGEMENT

HEALTH PERCEPTION & MANAGEMENT
History (subjective data): Client’s general health? Any colds in past year? If appropriate: any absences from work/school? Most important things you do to keep healthy? Use of cigarettes, alcohol, drugs? Perform self exams, i.e. Breast/testicular self-examination? Accidents at home, work, school, driving? In past, has it been easy to find ways to carry out doctor’s or nurse’s suggestions? (If appropriate) What do you think caused current illness? What actions have you taken since symptoms started? Have your actions helped? (If appropriate) What things are most important to your health? How can we be most helpful? done exercise every what? HEALTH PERCEPTION & MANAGEMENT

NUTRITIONAL/ METABOLIC
This pattern describes food and fluid consumption relative to metabolic need & pattern indicators of local nutrient supply. NUTRITIONAL/ METABOLIC

NUTRITIONAL/ METABOLIC
History (subjective data): Typical daily food intake including snacks? Use of supplements, vitamins? Typical daily fluid intake? Weight loss/gain? Height loss/gain? Appetite? Breastfeeding? Infant feeding? Food or eating: Discomfort, swallowing difficulties, diet restrictions, able to follow? Healing – any problems? Skin problems: lesions? Dryness? Dental problems? Examination (examples of objective data): Skin assessment, oral mucous membranes, teeth, actual weight/height, temperature. Abdominal assessment. NUTRITIONAL/ METABOLIC

DIET RECALL M T W TH F SA SU Breakfast (include time of meal) Snack
Lunch Dinner

Describes the pattern of excretory function (bowel, bladder, skin).
ELIMINATION Describes the pattern of excretory function (bowel, bladder, skin).

ELIMINATION History (subjective data):
Bowel elimination pattern (describe) Frequency, character, discomfort, problem with bowel control, use of laxatives (i.e. type, frequency), etc.? Urinary elimination pattern (describe) Frequency, problem with bladder control? Excess perspiration? Odour problems? Body cavity drainage, suction, etc.? Examination (examples of objective data): If indicated, examine excretions or drainage for characteristics, colour, and consistency. Abdominal assessment.

ACTIVITY/ EXERCISE This pattern describes activity level, exercise program, and leisure activities.

ACTIVITY/ EXERCISE History (subjective data):
Sufficient energy for desired and/or required activities? Exercise pattern? Type? regularity? Spare time (leisure) activities? Child-play activities? Perceived ability for feeding, grooming, bathing, general mobility, toileting, home maintenance, bed mobility, dressing and shopping? Examination (examples of objective data): Demonstrate ability for the following criteria: Gait. Posture. Absent body part. Range of motion (ROM) joints. Hand grip - can pick up pencil? Respiration. Blood pressure. General appearance. Musculoskeletal, cardiac and respiratory assessments.

ACTIVITY DIARY/RECALL
MONDAY, NOV. 7 ACTIVITIES 5:00 am Woke up 5:30 am Ate Breakfast 6:00 am Took a bath 6:30 am Dress up for school 7:00 am Walked to school 7:45 am Reached school Etc. Until sleeping time ACTIVITY DIARY/RECALL

Describes patterns of sleep, rest, and relaxation.

SLEEP/REST History (subjective data):
Generally rested and ready for activity after sleep? Sleep onset problems? Aids? Dreams (nightmares), early awakening? Rest / relaxation periods? Examination (examples of objective data): Observe sleep pattern and rest pattern if applicable Dark circles around the eyes, eye bags, yawning, inability to concentrate, etc.

SLEEP DIARY M T W TH F SA SU Time went to bed
Approximate time fell asleep Wake up period/ sleep interruptions (how long) Time woke up the next morning Feeling after waking up Naps(time slept & woke up; duration) Activities done before bedtime Bedtime rituals SLEEP DIARY

COGNITIVE/PERCEPTUAL
Describes the ability of the individual to understand and follow directions, retain information, make decisions, and solve problems. Also assesses the five senses.

COGNITIVE/PERCEPTUAL
History (subjective data): Hearing difficulty? Hearing aid? Vision? Wears glasses? Last checked? When last changed? Any change in memory? Concentration? Important decisions easy/difficult to make? Easiest way for you to learn things? Any difficulty? Any discomfort? Pain? COLDSPA C - Character O - Onset L - Location D - Duration S – Severity P - Pattern A - Associated factors (Weber, 2003) Examination (examples of objective data): Orientation. Hears whispers? Reads newsprint? Grasps ideas and questions (abstract, concrete)? Language spoken. Vocabulary level. Attention span.

SELF PERCEPTION/SELF CONCEPT
Describes client’s self-worth, comfort, body image, feeling state.

SELF PERCEPTION/SELF CONCEPT
History (subjective data): How do you describe yourself? Most of the time, feel good (or not so good) about self? Changes in body or things you can do? Problems for you? Changes in the way you feel about self or body (generally or since illness started)? Things frequently make you angry? Annoyed? Fearful? Anxious? Depressed? Not able to control things? What helps? Ever feel you lose hope? Examination (examples of objective data): Eye contact. Attention span (distraction?). Voice and speech pattern. Body posture. Client nervous (5) or relaxed (1) (rate scale 1-5) Client assertive (5) or passive (1) (rate scale 1-5)

ROLES/RELATIONSHIP History (subjective data): Live alone?
Family? Family structure? Any family problems you have difficulty handling (nuclear/extended family)? Family or others depend on you for things? How well are you managing? If appropriate – How families/others feel about your illness? Problems with children? Belong to social groups? Close friends? Feel lonely? (Frequency) Things generally go well at work / school? If appropriate – income sufficient for needs? Feel part of (or isolated in) your neighborhood? Examination (examples of objective data): Interaction with family members or others if present.

SEXUALITY/REPRODUCTIVE
History (subjective data): If appropriate to age and situation – Sexual relationships satisfying? Changes? Problems? If appropriate – Use of contraceptives? Problems? Female – when did menstruation begin? Last menstrual period (LMP)? Any menstrual problems? (Gravida/Para if appropriate) Examination (examples of objective data): None unless a problem is identified or a pelvic examination is warranted as part of full physical assessment (advanced nursing skill).

COPING/STRESS TOLERANCE
History (subjective data): Any big changes in your life in last year or two? Crisis? Who is most helpful in talking things over? Available to you now? Tense or relaxed most of the time? When tense, what helps? Use any medications, drugs, alcohol to relax? When (if) there are big problems in your life, how do you handle them? Most of the time, are these ways successful?

VALUE/BELIEF PATTERN Describes the patterns of values, beliefs (including spiritual), and goals that guides the client’s choices or decisions.

VALUE/BELIEF PATTERN History (subjective data):
Generally get things you want from life? Important plans for future? Religion important to you? f appropriate - Does this help when difficulties arise? If appropriate – will being here interfere with any religious practices? Health beliefs/values?

COMPLETE HEALTH HISTORY

8 Sections of a Complete Health History
Biographic data Reasons for seeking health care (Chief Complaint) History of present health concern Past health history Family health history Review of systems for current health problems Lifestyle and practices profile Developmental level

BIOGRAPHIC DATA Includes information that identifies the client
E.g. name, address, phone number, gender etc. Source of data: Client or significant others

REASON(S) FOR SEEKING HEALTH CARE
Also known as Client’s Chief Complaint (CC) We aim to determine the following: What brought the client to seek health care The feelings of the client about seeking health care Can be assessed by asking the following questions: “What is your major health problem or concerns at this time?” "How do you feel about having seeking health care?”

“What is your major health problem or concerns at this time?”
Assist the client to focus on his most significant concern Other questions like, “ Why are you here?” and “How can I help you?” can also be asked Reminder: use holistic approach in phrasing questions, draw out concerns that are beyond just a physical complaint and address other associated factors like stress or lifestyle changes

"How do you feel about having seeking health care?”
Encourages the client to discuss fears or feelings about having to seek health care advice. May help in determining descriptions of past experiences—both positive and negative—with other health care worker

HISTORY OF PRESENT HEALTH CONCERN
takes into account several aspects of client’s current health concern includes questions that provide detailed descriptions of the client’s health problem

Encourage the client to explain:
health problem or symptom focusing on onset, progression and duration signs and symptoms and related problems what the client perceives as causing the problem/symptom what makes the problem worse what makes the problem better which treatments have been tried what effect the problem has had on daily life what is the client’s ability to provide self-care

TIP: USE MNEMONICS To gather a comprehensive history of present concern as a nurse you may use the following mnemonic to organize data: PQRST or COLDSPA

Precipitating factors (What brought about the pain
Precipitating factors (What brought about the pain? What do you do to be relieved?) Quality/character (What the pain feels like? Piercing? Scalding? Crushing? Unbearable? Killing? Intense?, How does it look like?) Region/Radiation (Where do you feel the pain?) Severity (Use rating scale 0-10/ 1-10) Time/duration ( How long it lasts?) Character (how does it feel, look, smell, sound?) Onset (When did it begin: is it better, worse, or same since it began?) Location/radiation (Where is it? Does it radiate?) Duration (How long it lasts? Does it recur?) Severity (use rating scale) Pattern (What makes it better, worse?) Associated factors (What other symptoms do you have with it? Will you be able to continue doing your work or other activities ?)

PAST HEALTH HISTORY elicit data related to the client’s strengths and weaknesses in his health history Physical, social, emotional or spiritual may also include trends of unhealthy behaviors Vices or lack of physical activity data obtained in this section aids the nurse to identify risk factors that stem from previous health problems (risk factors may be to the client or significant others)

Past Health History includes questions about...
birth, growth and development childhood diseases immunizations allergies previous health problems hospitalizations and surgeries pregnancies births previous accidents and injuries pain experiences emotional or psychological problems

FAMILY HEALTH HISTORY focuses on health problems that seem to run in families or those that are genetically based should include as many genetic relatives as the client can recall include maternal and paternal grandparents, aunts and uncles on both sides, parents, siblings and the client’s children

FAMILY HEALTH HISTORY drawing a genogram helps to organize and illustrate the client’s family history use a standard format provide a key for the entries female relatives: circle male relatives: square deceased relative: marking an X in the circle or square and listing the age at death cause of death noted inside a parenthesis e.g. (heart failure ) AW (Alive and well) should be placed next to the age Straight or vertical lines to denote relationship Horizontal doted line to indicate client’s spouse Vertical dotted line to indicate adoption

Functional Assessment of Newborns, Infants & Children, Adults/Elderly
Newborn (APGAR Scoring & anthropometric measurements) Infants & Children (MMDST & some major developmental milestones) Adults/Elderly (PADC, Lawton Scale for IADL, KATZ index of independence on ADL, Barthel Index)

Initial Newborn Assessment...Apgar Scoring
provides numeric indicator of newborn’s physiologic capacity to adapt to extra-uterine life assessed at 1 and at 5 minutes after delivery each of the five aspects is assigned a maximum score of 2 maximum achievable total score is 10 score under 7 suggests that the baby is having difficulty score under 4 indicates that the baby’s condition is critical those with very low scores require special resuscitative measures and care

Initial Newborn Assessment...Apgar Scoring
Sign Score: 0 Score: 1 Score: 2 Heart Rate absent slow (below 100/min) over 100/min Respiration slow, irregular, hypoventilation regular rate, good lusty cry Muscle Tone flaccid some flexion of extremities active movements/flexion Reflex Irritability no response crying, some motion/grimace crying, coughing Color Blue (cyanotic), pale pink body, blue hands & feet pink body, pink extremities

Initial Newborn Assessment...Anthropometric Measurements
weight length head and chest circumference

Newborn’s Anthropometric Measurements...weight
details of the procedure will be dealt with in greater detail during NCM 101 and NCM 102 at birth most babies weigh from 2.7 to 3.8 kg (Kozier et al) to 4000 g (Weber & Kelly) just after birth, newborns lose 5% to 10% of their birth weight because of fluid loss (normal) regains birth weight in about 1 week at 5 to 6 months, infants usually reach twice their birth weight by age 12 months, infants weight is usually 3 times their birth weight weigh the newborn unclothed using a newborn scale

Newborn’s Anthropometric Measurements...length
average length varies female babies are usually smaller in length than male babies rate of increase in height/length is largely influenced by the baby’s size at birth and by nutrition measure the newborn from head-to-heel (from the top of the head to the base of the heels)

Newborn’s Anthropometric Measurements...head & chest circumference
normal head circumference (normocephaly) should be assessed in relation to chest circumference chest circumference of the newborn is usually less than the head circumference by about 2.5 cm (1 in) as the infant grows, chest circumference becomes larger than the head circumference at about 9 or 10 months, head and chest circumferences are almost the same after 1 year of age, chest circumference is larger a newborn’s head circumference is measured around the skull above the eyebrows measure chest circumference by placing tape measure at nipple line and wrap it around the newborn

Developmental Screening Test

Developmental Assessment of Infants and Children...MMDST
adopted from Denver Developmental Screening Test (DDST) a screening tool to identify developmental delays among children from birth to 6 years of age intended to estimate the abilities of a child compared to those of an average group of children of the same age not a test of intelligence

four main areas of development are screened: 1. personal-social 2. fine-motor adaptive 3. language 4. gross motor

personal-social – tasks which indicate the child’s ability to get along with people and to take care of himself fine motor adaptive – tasks which indicate the child’s ability to see and use his hands to pick up objects and to draw Language – tasks which indicate the child’s ability to hear, follow directions and to speak Gross motor – tasks which indicate the child’s ability to sit, walk and jump

Assessment of Infants and Children...Immunization Status
*antigen – a substance capable of inducing the formation of antibodies (ex. bacterial toxins) *antibodies – immunoglobulins; part of the body’s plasma proteins which serve as defense against bacterial and viral infections Immunization – the process by which resistance to an infectious disease is produced or augmented Types of Immunity: 1. active immunity – acquired when a person produces antibody in response to an antigen

Types of Immunity...continued
Active Immunity can either be: natural - exposure and/or recovery from an infection b. artificial - acquired through the injection of a small amount of attenuated (weakened) or dead organisms (vaccines) or modified toxins from the organism (toxoids) into the body.

Types of Immunity...continued
Passive Immunity – a resistance of the body to an infection in which the host receives natural (from the mother to her unborn child through placental transfer) or artificial antibodies produced by another source/host.

Assessment of Infants and Children
Assessment of Infants and Children...Immunization Schedule (Based on EPI, 2010) Schedule/Child’s Age Vaccines At Birth BCG1 and Hepatitis B1 1 and a half month/6 weeks after birth DPT1, OPV1, Hepatitis B2 2 and a half months/10 weeks after birth DPT2, OPV2 3 and a half months/14 weeks after birth DPT3, OPV3, Hepatitis B3 ***6 months ***Give Vitamin A 9 months Anti-Measles Vaccine + Vitamin A

Assessment of Infants and Children...Immunization Status
A child’s immunization status can be categorized as: incompletely immunized completely immunized fully immunized ***based on child’s age

Assessment of a Pregnant Woman
estimating delivery date (EDC/EDD) estimating gestational age (AOG/age of gestation maternal assessment (history)

Assessment of a Pregnant Woman...Estimating Delivery Date
Nagel’s Rule: subtract 3 months from the first day of the last menstrual period (LMP) and add 7 days. Ex: LMP= Oct. 5, 2010 Oct. 5 – 3months= July 3(because Aug. & July have 31 days) thus, EDD= July 3+7days=July 10, 2011

Assessment of a Pregnant Woman...Estimating Age of Gestation
through LMP using McDonald’s Rule fundal height in cm x 2/7 = AOG in months fundal height in cm x 8/7 = AOG in weeks

Assessment of a Pregnant Woman...Maternal History
age family history pregnant woman’s medical history pregnant woman’s past obstetric history pregnant woman’s present obstetric history

age as a risk factor: very young; older women family history: congenital disorders, multiple pregnancies, DM, heart disease, hypertension, mental retardation woman’s medical history: menarche, childhood diseases, major illnesses, surgery, blood transfusion, drug sensitivity, urinary infections, heart disease, diabetes, hypertension, endocrine disorders, anemia, use of contraceptives, drug abuse, alcohol and tobacco use

past obstetric history – previous pregnancies (gravida) and deliveries (parity), types of deliveries, multiple births (multipara), abortions, maternal, fetal and neoatal complications, perceptions of past pregnancies, labor and delivery

present obstetric history gravidity, parity LMP EDD signs and symptoms of pregnancy rest and sleep patterns activity and employment, if any sexual activity diet history, eating pattern, weight loss, weight gain

psychosocial status – emotional changes client is experiencing, reactions to the present pregnancy (including her family’s response), support system

Assessment of an Elderly Client
differentiate findings that result from the usual “wear and tear”/degenerative processes and those that indicate pathologic process “frail elderly”– vulnerability of aged people to be in poorer health, to have more chronic disabilities and to function less independently

symptoms of a disease may be more subtle in advanced age changes in functional abilities may herald the occurrence of a potential health problem recognizing changes in functional ability is often crucial for prompt and accurate management of both acute and chronic illness in an elderly

geriatric syndromes – the unique way in which a disease presents in a frail elderly. These syndromes include: sleep disorders problems with eating or feeding incontinence (bladder and bowel) confusion evidence of falls skin breakdown

Determining Functional Status of an Elderly
functional assessment – an evaluation of the person’s ability to carry out the basic self-care activities of daily living (ADLs) such as bathing, eating, grooming and toileting functional assessment also includes those activities necessary for well-being and survival as an individual in a society (instrumental activities of daily living

Instrumental Activities of Daily Living (IADL) – focus primarily on household chores, mobility-related activities (ex. shopping and transportation) and cognitive abilities (ex. money management, making decisions affecting basic safety and social needs) )...see display 30-8 on page 820 of your book by Weber & Kelly

Katz Activities of Daily Living – a commonly used tool for measuring the ability to perform basic personal tools such as bathing, dressing, toileting, transferring and eating...see display 30-7 on page 819 of your book by Weber & Kelly

Goal of Elderly Assessment
the ultimate goal of elderly assessment and intervention should be to empower clients to maintain the relationships, activities and events that elderly clients find meaningful elderly assessment may not be focused on disease prevention as it is on minimizing the disability associated with chronic illness and preventing complications and exacerbations of chronic maladies

Common Laboratory Exams
Complete Blood Count (CBC) urinalysis stool exam blood chemistry

Common Laboratory Exams...CBC
one of the most frequently ordered blood tests uses venous blood measures important blood components hemoglobin hematocrit erythrocyte (RBC) leukocyte red blood cell (RBC) indices differential white cell count

Common Laboratory Exams...Blood Chemistry
a test performed on blood serum (the liquid portion of the blood); may provide valuable diagnostic cues in addition to serum electrolytes (a screening test for electrolytes and acid-base imbalances), common blood chemistry examinations include certain enzymes that may be present in the blood (lactic dehydrogenase (LDH), creatinine kinase (CK), aspartate aminotransferase (AST), alanine aminotranferase (ALT), serum glucose, cholesterol, triglycerides

Common Laboratory Exams...Urinalysis
determines urine composition and possible abnormal components (glucose, ketones, proeins, blood) collecting urine specimens for a number of tests clean voided specimens – routine urinalysis clean-catch or midstream urine specimens – urine culture timed urine specimens – for a variety of tests that depend on the client’s specific health problem ***urine specimen collection may require collection via straight catheter insertion

Common Laboratory Exams...Stool Exam
*occult blood – possible bleeding from ulcers, inflammatory disease, or tumors *excessive amount of fats in the stool (steatorrhea) may indicate faulty absorption of fats from the small intestine *determining the microorganisms in the stool will help in identifying the appropriate treatment can provide information about a client’s health condition reasons for testing feces include: to determine the presence of occult (hidden) blood; also known as guaiac test to analyze for diatary products and digestive secretions to detect presence of ova and parasites to detect the presence of bacteria or viruses

Concepts 1 References: 1. Health Assessment in Nursing 3rd Edition by Janet Weber & Jane Kelley 2. Fundamentals of Nursing 7th Edition by Barbara Kozier et al 3. Fundamentals of Nursing 6th Edition by Patricia Potter & Ann Griffin Perry

HEALTH ASSESSMENT.

Similar presentations

Presentation on theme: "HEALTH ASSESSMENT."— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

HEALTH ASSESSMENT.

Similar presentations

Presentation on theme: "HEALTH ASSESSMENT."— Presentation transcript:

Similar presentations

About project

Feedback